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9/19/2011

"A Yale Psychologist Calls for the End of Individual Psychotherapy?" Did I read that correctly?

Here's the back story: a famous, well-respected psychologist writes a hugely complex journal article and then gives an interview to TIME Healthland online. The interview is as confusing as the journal article, and great controversy ensues in the profession.

Are people being mislead and confused? Are they being harmed? Does he have a valid point?

First, about the harm: yes, some people are going to read this as a confirmation of their pre-existing belief that psychotherapy is a waste of time. But that is not so much harm. People who are distressed and who realize that it might be a good idea to speak with a professional are going to continue to seek help. They are the ones who will actually benefit.

Does Dr. Kazdin have some good ideas? Yes. He spends a lot of time talking about the fact that psychological disorders and emotional troubles take a terrible toll on society and on the health of individuals.

He also thinks that therapists should be able to offer a "portfolio of interventions." It is not at all a bad idea to use smart phones and the internet and other technologies to provide some treatments, as he suggests.

Dr. Kazdin is in favor of prevention and in favor of expanding treatment options. He wants more people to be trained.

That article was about a movement in the profession to create a new model for understanding mental illness, a model that views science and the scientific method in a very narrow way.

The goal of the "empirically based treatment" movement is to say that there is one particularly correct way to evaluate the usefulness of treatment. They say that the only measures that should be used are like the ones they use to test new drugs: randomized controlled trials ("RCTs"). And from that follows the assertion that therapy isn't worth doing if you don't deliver the treatment according to a standardized protocol.

That in turn means that psychologists all should be trained in some specific way and that we need new training standards to make that happen. As for those of us who studied liberally and broadly in preparation for our work in understanding the human condition, well, some of us are just too old to catch on to the new way of doing things.

This article tries to incorporate that entire agenda. The journal article reads like a master treatise on the state of mental health in America and the difficult path towards salvation. Kazdin et al are advocating for the "Machine in the Garden," the technology that will transform the human condition.

Where Kazdin and others go wrong is in believing they can fully operationalize what is typically a unique and essentially human interaction.

There are certainly times when it is relevant to focus on the diagnosis and the symptoms and to apply techniques that have proven their worth in a head-to-head matchup with a drug and a placebo. "Cognitive Behavioral Therapy" done right and by the book is a godsend for many.

For most people, however, the decision to talk to someone and to be honest is a very personal decision and a very personal matter.

It's like when you call your bank or tech support: you're sitting there punching those keys, doing whatever you can to get connected to a human being.

People benefit from therapy in a number of ways and for different reasons. It is not like speaking to a friend or a family member and it is something different than having your blood pressure checked or your tonsils removed.

Early in my training, I was told that what people want when they seek a psychologist's help is someone who will be honest with them. People are relieved and strengthened not because you trained them to tolerate their anxiety or to brood less about their disappointments. People are relieved when they know that someone has listened to them and understood them, and when they experience themselves trusting someone.

The metaphor for the psychotherapeutic process is sometimes that of a sanctuary, a place of safety, and sometimes that of a crucible, a place where work can be done. There are other metaphors that can be applied, but the consistent finding from the science is that individual therapy works ... for many individuals and in many situations.

Sometimes, it is useful to drag out a protocol and to apply some empirical treatment rules. More often, people benefit from treatment because they have found a personal guide, rather than someone with a guidebook.

Is individual psychotherapy bound for the dustbin of history? No, not at all.

People in distress are not going to stop seeking personal solutions to their personal problems, just because some empiricist claims there is a better technology. Psychologists are not the type of professionals who would ever ignore the science. But we are also not the type to seek simple solutions to complex problems or to understand things narrowly when a broader perspective is called for.

The number of clinicians who use "the couch" instead of a chair will always be limited. That does not mean that the lessons learned from "the couch" will be lost or that we are soon to see the end of TAU: "therapy as usual." Even though you can't put it in a bottle, prescribe it and market it, it remains a proven method.